Form Temp 2202 - Cash Aid/food Stamp Electronic Benefit Transfer - Ebt Service Request

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH AID/FOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT
SERVICE REQUEST
DATE
CLIENT NAME
CASE NUMBER
County Service Counter Request
Request Designated Alternate Card Holder
Request Authorized Representative
Reactivate
Replace
Card
PIN
Explain____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If you are here to report a lost or stolen EBT Card, call toll free 1-877-328-9677 IMMEDIATELY.
Other (Explain)______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I have received a copy of this service request.
CLIENT OR DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE
PHONE
DATE
Date
Issued Card
Yes
No ________
Issued PIN
Yes
No ________
Reactivate
Yes
No ________
Account
Worker Initials ________
TEMP 2202 (7/02) REQUIRED FORM - SUBSTITUTE PERMITTED

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